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Promoting Patient Safety.

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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for CE without a fee and trainings. The platform provides powerful searching and browsing capability, as well as the ability for users to customize the site around their interests (My Profile).

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January 8, 2025 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.

Review
Gursel E, Madadi M, Coble JB, et al. Reliability Eng System Saf. 2025;256:110682.
Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human error in safety-critical industries, the limitations and challenges of AI/ML, and insights from the recent literature. Examples from health care include using AI to detect diagnostic errors and combining AI with clinician expertise,...
Review
Patel SM, Fuller S, Michael MM, et al. Anesth Analg. 2024;Epub Nov 26.
Mnemonics are a commonly used memory aid to ensure standardized, structured handoffs between providers. This review summarizes mnemonics used in perioperative handoffs. Situation, Background, Assessment, Recommendation (SBAR) and SBAR variations were the most common, followed by I-PASS (Illness severity, Patient summary, Actions list, Situation awareness, Synthesis), and I-PASS variants. Most studies...
Study
Schmidt M, Schauwinhold MT, Loeffler LAK, et al. Ann Med. 2024;56:2408458.
Learning from errors is a fundamental component of health professions education. This randomized trial examined the difference between two error-framing strategies—Error Management (EM) and Error Avoidance (EA)— on cardiopulmonary resuscitation (CPR) performance among first-year health professions students. The EA perspective aims to avoid errors as much as possible, even during the learning process. In...
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Training and Education

Update Date: December 18, 2024

WebM&M Case Studies & Spotlight Cases

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CE. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

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Improvement Resources
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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

Toolkit
Toolkits

Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.

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